Neighbourhoods for Life

Designing dementia-friendly outdoor environments

Checklist of characteristics of
dementia-friendly neighbourhoods

A familiar environment
o Places and buildings are long established with any change being small-scale and incremental

o The functions of places and buildings are obvious

o Architectural features and street furniture are in designs familiar to or easily understood by
older people

A legible environment
o There is a hierarchy of street types, such as main streets, side streets, alleyways and passages

o Blocks are small and laid out on an irregular grid based on an adapted perimeter block pattern

o Streets are short and fairly narrow

o Streets are well connected and gently winding with open ended bends to enable visual continuity

o Forked and t-junctions are more common than crossroads

o Latent cues are positioned where visual access ends, especially at decision points, such as
junctions and turnings

o Entrances to places and buildings are clearly visible and obvious

o Signs are minimal, giving simple, essential information at decision points

o Signs have large graphics with realistic symbols in clear colour contrast to the background,
preferably dark lettering on a light background

o Directional signs are on single pointers

o Signs locating important places and buildings are perpendicular to the wall

o Signs have non-glare lighting and non-reflective coverings

A distinctive environment
o Urban and building form is varied

o There is a variety of landmarks including historic and civic buildings, distinctive structures and
places of activity

o There is a variety of welcoming open spaces, including squares, parks and playgrounds

o Architectural features are in a variety of styles, colours and materials

o There is a variety of aesthetic and practical features, such as trees and street furniture
An accessible environment
o Land uses are mixed

o Services and facilities are within 5-10 minutes walking distance of housing

o Footpaths are wide and flat

o Pedestrian crossings and public toilets are at ground level

o Unavoidable level changes have gentle slopes with a maximum gradient of 1 in 20

o Entrances to places and buildings are obvious and easy to use

o Gates/doors have no more than 2kg of pressure to open and have lever handles

A comfortable environment
o The outdoor environment is welcoming and unintimidating

o Urban areas have small, well-defined open spaces with toilets, seating, shelter and lighting

o There are quiet side roads as alternative routes away from crowds/traffic

o Some footpaths are tree-lined or pedestrianised to offer protection from heavy traffic

o Acoustic barriers, such as planting and fencing, reduce background noise

o Street clutter, such as a plethora of signs, advertising hoardings and bollards is minimal

o Telephone boxes are enclosed

o Bus shelters are enclosed and have seating

o Seating is sturdy with arm and back rests and in materials that do not conduct heat or cold

A safe environment
o Footways are wide, well maintained and clean

o Bicycle lanes are separate from footways

o Pedestrian crossings have audible cues at a pitch and timing suitable for older people

o Paving is plain and non-reflective in clear colour and textural contrast to walls

o Paving is flat, smooth and non-slip

o Trees close to footways have narrow leaves that do not stick to paving when wet

o Spaces and buildings are oriented to avoid creating areas of dark shadow or bright glare

o Street lighting is adequate for people with visual impairments

o Level changes are clearly marked and well lit with handrails and non-slip, non-glare surfaces
Neighbourhoods for Life

Designing
dementia-friendly
outdoor environments

A Findings Leaflet by
Elizabeth Burton,
Lynne Mitchell
and Shibu Raman
Neighbourhoods for Life
Designing dementia-friendly outdoor environments

The Wellbeing in Sustainable Environments Research Unit of the Oxford Institute for Sustainable
Development has recently concluded a three-year research project, funded by the Engineering and Physical
Sciences Research Council’s EQUAL programme, examining how the outside environment could be made
dementia-friendly. This unprecedented research investigated the perceptions, experiences and use of the
outdoor environment by older people with dementia and identified design factors that influence their ability
to successfully use and negotiate their local neighbourhoods. The findings have enabled the researchers to
provide some preliminary guidance for designers, at all scales from urban design to street furniture, on the
criteria to consider in developing dementia-friendly urban areas.

Summary of key findings

• Older people with dementia, particularly in
the mild to moderate stages, continue to
go out alone, many daily.
• Older people with dementia tend to limit
their outside activities to relatively
undemanding situations, such as going to
the corner shop, posting a letter or going
for a walk.
• Older people with dementia tend to use cars
or public transport only when accompanied
by others so that independent outside
activity is restricted to the immediate
neighbourhood within walking distance of
home.
• Although the interaction of older people
with dementia with the outdoor
environment is limited, it is clear that it
provides some sense of independence and
self-respect at a time when they are losing
control over their own abilities and lives.
• Older people with dementia generally enjoy
going out but anxiety, disorientation or
confusion can occur in complex, crowded
or heavily trafficked places or when startled
by sudden loud noises.
• Older people with dementia tend to be less
aware of physical and social dangers in the
outdoor environment and of the possibility
of losing the way than older people without
dementia.
• Older people with dementia cannot always
interpret the cues that signal the use of
buildings, the location of entrances or the
behaviour that is expected in different places.
• Older people with dementia continue to plan
and visualise proposed routes and tend to
use landmarks and other visual cues rather
than maps and written directions as
wayfinding techniques.
• Older people with dementia tend to prefer:
3 mixed-use, compact local neighbourhoods
3 short, gently winding streets with wide
pavements and good visual access
3 varied urban form and architectural
features
3 quiet, pedestrianised streets and
welcoming open spaces
3 places, spaces and buildings whose
functions and entrances are obvious
3 simple, explicit signs with large, dark,
unambiguous graphics on a light
background
3 historic, civic or distinctive landmarks
and practical or aesthetic environmental
features
3 smooth, plain, non-slip, non-reflective
paving
3 easy to use street furniture in styles
familiar to older people.
• Dementia-friendly neighbourhoods are
places that are familiar, legible, distinctive,
accessible, comfortable and safe
Background
The number of older people in the UK is rising
dramatically, particularly in the age group of 85 years
and above. As the likelihood of developing dementia
increases with age, reaching a one in five chance
over the age of 80, the number of people with
dementia in the UK is also growing. The Disability
Discrimination Act 1995 recognises disability as
including cognitive and sensory as well as physical
impairments and expected all barriers restricting the
access and use of services by disabled people to
have been removed by 1 October 2004.
With limited spaces available in care facilities, most
older people with mild to moderate dementia live in
their own homes. Research has shown that
remaining in the familiar surroundings of home and
the local neighbourhood can have beneficial effects
cognitively, physically and emotionally. However, to
live successfully in the community people with
dementia need outdoor environments that are
designed to help rather than hinder. If they are
unable to enter or use their local neighbourhoods
they will become effectively housebound. To date
there is little knowledge on design for dementia in
the outdoor environment.
About the study
The study aimed to find out how to create dementia-
friendly neighbourhoods that enhance and extend
the active participation of older people with
dementia in their local communities. The objectives
of the study were as follows:
• To investigate how older people with dementia
interact with the outdoor environment, the nature
and quality of their experiences, and their
understanding of the outdoor environment
• To identify design factors that influence the ability
of older people with dementia to successfully use
the outdoor environment
• To offer preliminary guidance (at all scales, from
urban design to the design of street furniture) for
designing dementia-friendly outdoor environments
Forty-five ambulant people aged 65 or over, living at
home or in sheltered accommodation and still using
the outdoor environment, participated in the
research. Twenty were also in the mild to moderate
stages of dementia, with a Mini-Mental State
Examination score of between 8 and 20.
All participants were interviewed to determine their
perceptions and use of the outside environment.
Many were also accompanied on short walks within
their local neighbourhood to record their wayfinding
techniques and the environmental features that
appear to help or hinder them. The environmental
characteristics of participants’ local neighbourhood
were also measured.
How older people with dementia
interact with the outdoor environment
Most of the participants with dementia and all of
those without dementia go out alone, over half in each
group daily. All go shopping and about half also
regularly visit the local post office, park or take walks
around their local neighbourhood. Participants with
dementia tend to avoid socially demanding situations,
such as visiting friends or attending church, preferring
less exigent activities, such as going to the corner
shop or posting a letter.
Participants with dementia are far more physically
restricted in their independent use of the outdoor
environment than those without dementia. As they no
longer drive or use public transport unaccompanied
their choice of destination is limited to within walking
distance of home. Participants with dementia are also
significantly less likely than those without dementia to
visit more than one place in a single trip.
The nature and quality of experiences
of older people with dementia in the
outdoor environment
The participants with dementia tend to prefer informal
places, such as streets and parks, and feel intimidated
in formal places such as public squares with imposing
architecture. However, in interviews, they were far less
likely than those without dementia to say that they
face any problems when they are out. The few who did
refer to problems focused on physical impairments,
such as poor eyesight or an unsteady gait. In
comparison, participants without dementia discussed
a variety of physical problems including uneven
paving, poor seating, bicycles on footpaths and steep
inclines. They also referred to social and psychological
difficulties, such as the closure of local shops, poor
bus services, and the fear of attack or of getting lost.
Findings from the accompanied walks showed that
people with dementia do face similar problems to
those described by participants without dementia but
are less aware of them.
Participants described experiencing many different
emotions when in the outdoor environment, from
feeling happy or comfortable to boredom or anxiety.
However, the majority said that they enjoy going out,
although some are anxious about being out at night or
in unfamiliar places. Comments such as “the world
belongs to me for that time” and “I feel in charge of
myself” demonstrate the importance of getting
outdoors for their self-respect and independence. In
general, participants enjoyed the accompanied walks.
None of the participants without dementia showed
signs of anxiety, confusion or fear. However, around
half those with dementia were anxious or confused
when they were unsure of the route or distracted by
sudden noises.
How older people with dementia
understand the outdoor environment
When interviewed, fewer participants with dementia
said that they sometimes lose their way than those
without dementia; however, carers confirmed that a
higher number of participants with dementia get lost.
On the accompanied walks, none of the people
without dementia and one-third of participants with
dementia lost the way.
People with dementia often struggle to interpret the
cues that signal the use of buildings, the location of
entrances, the behaviour that is expected in different
places or the intentions of people around them. The
participants with dementia are able to understand
places, streets, buildings and features that are in
designs recognisable to older people. It appears that
style (whether traditional or modern) is less
important than clarity of function and use. They also
continue to remember features that they encounter
on a regular basis.
Design factors that help older people
with dementia use and enjoy their
local neighbourhoods
The majority of all the participants find simple, well-
connected street layouts with uncomplicated road
junctions the easiest to understand and to use.
Routes with varied urban form and architectural
features, such as doors, windows, roofing lines, tiles
and chimney pots, in a variety of styles, help to
maintain their concentration. However, disorientation
occurs amongst some people with dementia even in
familiar, straightforward and interesting
neighbourhoods when distracted by heavy traffic,
crowds or sudden loud noises.
Most of the participants plan the route they are
going to take and visualise it as they walk along.
Many will ask for directions if lost but those with
dementia often find maps and written directions
difficult to follow. Although most participants said
that they do not look for wayfinding cues, with “I just
know the way” being a common statement, the
accompanied walks demonstrated that a number of
features are used to clarify location and route. These
include historic or civic landmarks, such as war
memorials and churches; distinctive structures, such
as water towers or public art, and places of activity,
including urban squares, parks and playgrounds.
Practical features, such as telephone and post
boxes, and aesthetic features, such as gardens and
trees, are also used, providing they were not too
numerous to cause an excess of external stimuli.
Again, the important characteristics of the
wayfinding cues are that they are of unambiguous
design, are varied and interesting, and are regularly
encountered.
Dementia-friendly outdoor
environments
Our findings show that there are six major
requirements for outdoor environments to be
dementia-friendly: they need to be familiar, legible,
distinctive, accessible, comfortable and safe. Our
preliminary recommendations for meeting these six
requirements are presented in a checklist at the end
of the leaflet.
In summary, however, dementia-friendly local
neighbourhoods tend to be mixed use with a
hierarchy of street types, varied urban form and a
variety of landmarks and environmental features in
designs familiar to or easily understood by older
people. They have welcoming open spaces and
short, well-connected, gently winding streets with
good visual access. Footpaths are wide with
smooth, plain, non-slip, non-reflective paving. Signs
are simple and explicit and located at decision
points, such as road crossings and junctions.
Conclusions
This is preliminary research in an area that to date
has been neglected. As the findings are based on
a relatively small sample of older people with
dementia, further research would be beneficial to
improve representativeness and to ensure that the
design suggestions do not conflict with the needs
of people with physical impairments, such as
wheelchair users or those with visual impairments.
Environments that are easy for people to access,
understand, use and enjoy are beneficial to
everyone, not just older people with dementia.
Incorporation of the characteristics of dementia-
friendly environments into inclusive urban design
therefore has the potential to provide
‘Neighbourhoods for Life’. These would allow
people to live in their own homes and
communities for as long as they wish and to
maximise the quality of life of all residents, not
only those with dementia.
Further information
Lynne Mitchell
Oxford Institute for Sustainable Development
Department of Architecture
School of the Built Environment
Oxford Brookes University
Headington Campus
Gipsy Lane
Oxford OX3 0BP
01865 484296
lmitchell@brookes.ac.uk
2004